Posts from health care

Nuclear power (both fission and fusion) has the potential to provide much of the energy the world needs without the damaging effects of carbon emissions which are warming our planet.

And yet nuclear power is politically unpopular in many parts of the world and that has led to a massive underinvestment in nuclear power over the last fifty years. It will take a much different attitude about nuclear power among the public before nuclear power can remerge as a major source of energy for the world.

That is but one example of very promising technologies that suffer from negative public opinion.

Web3, which will usher in a different way of engaging with web services also suffers from a negative public perception. And yet a web3 that allows users to control their data with web services that will need our permission to use it offers a radically better model for the web as we know it.

Vaccines, which are one of the most important public health innovations of the last hundred years also suffer from negative public perception. Way too many people don’t trust vaccines and don’t avail themselves of them.

So what can those of us in the business of creating and bringing these important technologies to market do to reverse these negative opinions?

I believe that getting these technologies into market and showing people their benefits is the very best thing we can do.

For nuclear, that means smaller, safer, and more “personal” nuclear power. There are pacemakers that have nuclear batteries in them. Why not put way more nuclear powered devices into our lives and show that the benefits massively outweigh the risks?

For web3, that means shipping applications that mainstream users will use and see the benefits of controlling and provisioning their data. I think gaming and social applications are likely to be the first mainstream web3 applications because not everyone is a trader or investor. Mainstream means our parents and our children.

For vaccines, it means better and more effective vaccines. It means easier delivery (like nasal sprays). And it means less side effects. It’s hard to be enthusiastic about a wellness benefit that makes you feel like shit for a day or two.

All of these industries have large public policy organizations and spend lots of money on changing public perception. I’m absolutely in favor of that.

But there is nothing better than putting amazing technology in the hands of ordinary people and changing their lives for the better. That moves public perception more powerfully than anything else.

Yesterday, I had a gap in the middle of the day. So the Gotham Gal and I took an hour-long walk with our dog Ollie. It cleared my head and when I got back to work, I was full of energy and clarity.

I’ve been working exclusively from home since the end of November 2019 when we left NYC to go to LA. It has been a stretch of incredible productivity for me.

I am not arguing against going back to the office. As I’ve said in many posts recently, I can’t wait to go back to the office. But I am sure that many of us have had the same experience that I have had working from home during the pandemic. It has its advantages.

And in that realization exists the possibility that we are on the cusp on a revolution in how many of us can find work life balance going forward.

My friend Tom wrote this post last week suggesting that a husband and wife can now work a total of 50 hours a week between them and have two full-time jobs and raise a family. This part sums up the idea pretty well:

Why do I think 25 hours/ week is the equivalent of a 50-hour week (counting commuting)?

Given a nine-to five schedule with an hour for lunch, the 40 hour work week was only 35 to begin with.

As an ex-CEO, I think that at least ten hours of each workweek go to socialization, surfing the internet, checking with the spouse or checking up on the children, chatting on smartphones etc. (Mary thinks only five).

Meetings and travel to meetings waste a huge amount of time and money. One reason that Zooming appears not to have reduced productivity is that many of the meetings weren’t productive to begin with.

Office space and often parking are expenses to the employer but they are not income to the worker. If office space and all its attendant costs can be drastically reduced, employers can afford to pay more dollars in salary for the same productivity.

Commuting expense including perhaps even the second car, daycare, clothing and dry-cleaning bills, and paid before and after school activities whose purpose is to supervise school age kids are all expenses which go away when parents can work from home. Even if the WFH employee has less gross taxable income, he or she will have more cash at the end of each month.

https://blog.tomevslin.com/2021/01/newnormal-the-50-hour-family-work-week.html

Even if Tom is off by a bit with his math, he makes a terrific point. Companies can ask for less of a family’s time, pay them more, and get the same amount of work done using the techniques we have perfected during the pandemic.

I realize that not all jobs lend themselves to this approach. But maybe more than you think. Take doctors. We used to have to go see doctors in their offices. Now with digital health services like those offered by our portfolio companies Brave and Nurx, the doctors are seeing the patients from their homes (or wherever they are).

Teaching is another occupation that presents a lot of opportunity to rethink time and location. Many teachers have been learning how to help their students master new things from their kitchen counters over the last year.

I want to say it again. I am not suggesting that we won’t be going to offices anymore. I am not saying doctors won’t have offices anymore. I am not saying teachers won’t be in classrooms anymore.

What I am saying is that we can and should be asking how much of our work time needs to be in person, face to face, and how much can be virtual. And I am certain that we will be asking that. In our year-end reviews at USV, we heard again and again from our team that they wanted to ask those questions. They should. Commuting and business travel are not the necessities they were last century.

And, naturally, this coming work-life balance revolution presents tremendous opportunities for new products, services, and companies. We have been seeing many of them crop up over the last year and have invested in a few of them.

From bad comes good. This pandemic and all of the things that have come with it has been awful. But I believe it will unleash all sorts of new behaviors and businesses that will be for the better. If you squint, you can see them coming.

As I wrote about a few weeks ago, I am excited about the possibility that technology, particularly mobile computing technology, can supplement the work of manual contact tracing to keep us all safer until a permanent solution is found to this pandemic.

But there is a ton of confusion about what contact tracing is, what exposure alerting is, what the role of legacy contact tracing systems are, and what role new applications can play in this moment.

So I was thrilled that a group of organizations that operate at the intersection of public policy and tech innovation are putting on a series of online conferences on this topic.

The first one will be next Wednesday from 11am ET/8am PT until 2pm ET/11am PT and will focus on the consumer apps that are being built on top of the Google and Apple APIs. There will be demos of many of these new apps and a series of panel discussions. If you are interested in attending (attendance is unlimited), you can RSVP here.

There are four of these online events planned over the next two months (roughly every two weeks) and they will cover enterprise contact tracing applications, what is happening internationally, and more.

The organizations behind this series of online events are The COVID Tech Task Force, Harvard’s Berkman Klein Center, NYU’s Alliance for Public Interest Technology, TechCrunch, Betaworks Studios, and Hangar.

If you work in government and are involved in making tech decisions in this area, if you are interested in how tech can help address large scale public health issues, or if you are just curious about all of this, I hope you will attend. I plan to do that myself.

There is no doubt that the healthcare system in the US could use some work. We spend way too much and the quality of the healthcare that many receive is not where it could or should be. We allocate too much of our healthcare spending in the last few months of a person’s life and not nearly enough on preventive care throughout our lives. We are not leveraging the power of technology enough to help treat diseases and other conditions early when the treatments are more effective. So I am all for modifications to our health care system that will allow for more innovation, more preventive and wellness care, and more engagement with the system.

What I am not for is a total and complete dismantling of the Affordable Care Act and a return to a time when many US citizens did not have a means to pay for the healthcare they need (ie insurance). The Congressional Budget Office predicts that the Republican plan that has been put forth will cause 15mm US citizens to lose their insurance in the near term and up to 24mm over the longer term (by 2026).

This would just take us back to the time when a large percentage of our population had no other option but to defer healthcare until they got really sick and then show up in hospital emergency rooms and stick the “system” (ie those with insurance) with the bill. This is not a good way to run our healthcare system. Sure it might enable the government to remove the mandate that everyone have insurance, which sticks in the craw of conservatives and libertarians, but the cost of doing so means less preventive care, less outpatient care, and more costly end of life care.

I believe citizens of the US should have healthcare insurance. If they can afford it, they should pay for it. If they can’t afford it, society should pay for it. But one way or another, everyone should have the ability to see a doctor regularly, get preventive care, find diseases early on and treat them, and not defer their medical needs until they become acute.

The Republican plan seems hastily drawn up, largely a political reaction to the Affordable Care Act, and a return to a time when the wealthy can afford healthcare and many others cannot. I would encourage the President, his team, and the Republican members of Congress to go back to the drawing board and come up with something that moves us forward, not takes us back.

Last year in my What Just Happened post, I said:

the social media phase of the Internet ended

I think we can go further than that now and say that sometime in the past year or two the consumer internet/social/mobile gold rush ended.

Look  at the top 25 apps in the US:

The top 6 mobile apps and 8 of the top 9 are owned by Facebook and Google. 10 of the top 12 mobile apps are owned by Apple, Facebook, and Google.

There isn’t a single “startup” on that list and the youngest company on that list is Snapchat which is now over four years old.

We are now well into a consolidation phase where the strong are getting stronger and it is harder than ever to build a large consumer user base. It is reminiscent of the late 80s/early 90s after Windows emerged as the dominant desktop environment and Microsoft started to use that dominant market position to move up the stack and take share in all of the important application categories. Apple and Google are doing that now in mobile, along with Facebook which figured out how to be as critical on your phone as your operating system.

I am certain that something will come along, like the Internet did in the mid 90s, to bust up this oligopoly (which is way better than a monopoly). But it is not yet clear what that thing is.

2015 saw some of the candidates for the next big thing underwhelm. VR is having a hard time getting out of the gates. Wearables and IoT have yet to go mainstream. Bitcoin and the Blockchain have yet to give us a killer app. AI/machine learning has great potential but also gives incumbents with large data sets (Facebook and Google) scale advantages over newcomers.

The most exciting things that have happened in tech in 2015 are happening in verticals like transportation, hospitality, education, healthcare, and maybe more than anything else, finance, where the lessons and playbooks of the consumer gold rush are being used with great effectiveness to disrupt incumbents and shake up industries.

The same is true of the enterprise which also had a great year in 2015. Slack, and Dropbox before it, shows how powerful a consumerish approach to the enterprise can be. But there aren’t many broad horizontal plays in the enterprise and verticals seems to be where most of the action was in 2015.

I’m hopeful that 2015 will also go down as the year we buried the Unicorn. The whole notion that getting a billion dollar price tag on your company was something necessary to matter, to be able to recruit, to be able to get press, etc, etc, is worshiping a false god. And we all know what happens to those who do that.

As I look back over 2014 and 2015, I feel like these two years were an inflection point, where the underlying fundamentals of opportunity in tech slowed down but the capital rushing to get invested in tech did not. That resulted in the Unicorn phase, which if it indeed is over, will be followed by an unwinding phase where the capital flows will need to line up more tightly to the opportunity curve.

I’m now moving into “What Will Happen” which is for tomorrow, so I will end this post now by saying goodbye to 2015 and hopefully to much of the nonsense that came with it.

I did not touch on the many important things that happened outside of tech in 2015, like the rise of terrorism in the western world, and the reaction of the body politic to it, particularly here in the US with the 2016 Presidential campaign getting into full swing. That certainly touches the world of tech and will touch it even more in the future. Again, something to talk about tomorrow.

I wish everyone a happy and healthy new year and we will talk about the future, not the past, tomorrow.

Last year, I ended 2014 with What Just Happened and started 2015 with What Is Going To Happen.

I’ll do the same tomorrow and friday, but today I’d like to talk about What Didn’t Happen, specifically which of my predictions in What Is Going To Happen did not come to be.

1. I said that the big companies that were started in the second half of the last decade (Uber, Airbnb, Dropbox, etc) would start going public in 2015. That did not happen. Not one of them has even filed confidentially (to my knowledge). This is personally disappointing to me. I realize that every company should decide how and when and if they want to go public. But I believe the entire startup sector would benefit a lot from seeing where these big companies will trade as public companies. The VC backed companies that were started in the latter half of that last decade that did go public in 2015, like Square, Box, and Etsy (where I am on the board) trade at 2.5x to 5x revenues, a far cry from what companies get financed at in the late stage private markets. As long as the biggest venture backed companies stay private, this dichotomy in valuations may well persist and that’s unfortunate in my view.
2. I said that we would see the big Chinese consumer electronics company Xiaomi come to the US. That also did not happen, although Xiaomi has expanded its business outside of China and I think they will enter the US at some point. I have a Xiaomi TV in my home office and it is a really good product.
3. I predicted that asian messengers like WeChat and Line would make strong gains in the US messenger market. That most certainly did not happen. The only third party messengers (not texting apps) that seem to have taken off in the US are Facebook Messenger, WhatsApp and our portfolio company Kik. Here’s a shot of the app store a couple days after the kids got new phones for Christmas.
4. I said that the Republicans and Democrats would find common ground on challenging issues that impact the tech/startup sector like immigration and net neutrality. That most certainly did not happen and the two parties are as far apart as ever and now we are in an election year where nothing will get done.

So I got four out of eleven dead wrong.

Here’s what I got right:

1. VR has hit headwinds. Oculus still has not shipped the Rift (which I predicted) and I think we will see less consumer adoption than many think when it does ship. I’m not long term bearish on VR but I think the early implementations will disappoint.
2. The Apple Watch was a flop. This is the one I took the most heat on. So I feel a bit vindicated on this point. Interestingly another device you wear on your wrist, the Fitbit, was the real story in wearables in 2015. In full disclosure own a lot of Fitbit stock via my friends at Foundry.
3. Enterprise and Security were hot in 2015. They will continue to be hot in 2016 and as far as this eye can see.
4. There was a flight to safety in 2015 and big tech (Google, Apple, Facebook, Amazon) are the new blue chips. Amazon was up ~125% in 2015. Google (which I own a lot of) was up ~50% in 2015. Facebook was up ~30% in 2015.  Only Apple among the big four was down in 2015 and barely so. Oil on the other hand, was down something like 30% in 2015 and gold was down something like 15-20% in 2015.

Here’s what is less clear:

1. Bitcoin had a big comeback in 2015. If you look at the price of Bitcoin as one measure, it was up almost 40% in 2015. However, we still have not see the “real decentralized applications” of Bitcoin and its blockchain emerge, as I predicted a year ago, so I’m not entirely sure what to make of this one. And to make matters worse, we now seem to be in a phase where investors believe you can have blockchain without Bitcoin, which to my mind is nonsense.
2. Healthcare is, slowly, emerging as the next big sector to be disrupted by tech. The “trifecta” I predict will usher in an entirely new healthcare system (smartphone becomes the EMR, p2p medicine, and a market economy in healthcare) has not yet arrived in full force. But it will. It’s only a matter and question of when.

So, I feel like I hit .500 for the year. Not bad, but not particularly impressive either. But when you are investing, batting .500 is great because you can double down on your winners and stop out your losers. That’s why it is important to have a point of view, ideally one that is not shared by others, and to put money where your mouth is.

The Gotham Gal looked up from her laptop yesterday and said to me “I’m seeing a ton of health care deals right now.” I looked up from my Kindle app and nodded.

Mary Meeker’s slide deck addressed this is bit. Here are a few of the big points from it:

Healthcare is now $2.8 trillion in the US, which represents 17% of GDP

Healthcare is being consumerized

Healthcare is being digitized

Digital Health Venture Investment was $1.9bn in 2013 (out of a total of $24bn)

I listed health care as one of four “sectors” in my LeWeb talk last fall and when asked recently what excites me most, I mentioned the “mobilization of health care”.

The Gotham Gal has been making a bunch of these kinds of angel investments this year. She’s closed two and has a third in her pipeline. That’s somewhere between 25% and 33% of her investment activity right now. As Mary’s data shows, digital health is approaching 10% of all VC activity.

At USV, we’ve been looking hard at this sector but have only made one investment so far, in HumanDX. Albert explained the investment thesis behind HumanDX here.

We’ve made a few other offers but got outbid pretty badly on them. There is a lot of heat around this sector right now.

We are looking for networks of users, patients, doctors, and other stakeholders in our health care who can transform the way health care is delivered. We only have one game plan at USV and look to play it in every market opportunity we see.

I am pretty certain the intersection of the Internet and mobile, the digitization of the health care system, and a desire for people to take more control over their health is going to be one of the biggest investment opportunities we will see in my lifetime. And its game on.

A couple days ago, I saw a tweet by Henry Blodget and replied:

@hblodget @TheStalwart yup. here is the seminal book on that http://t.co/nNGStKDiCy this is not war. surges don't work. open source it

— Fred Wilson (@fredwilson) October 21, 2013

I am really upset by the problems with healthcare.gov. Leaving aside all the issues with Obamacare, and I hope and pray this discussion does not downgrade into a debate about that, I am very excited about the potential of marketplaces and marketplace economics on the price, availability, and transparency of healthcare insurance. It is way too complicated to buy healthcare insurance today and it costs way too much. The Internet and the power of marketplace economics has the potential to change that.

But our government has badly botched the construction of healthcare.gov and is now proposing a tech surge to fix it. More people, more money, and more promises thrown at a badly broken process. This will end about as well as Afghanistan and Iraq.

I'd like to suggest another way. Open source the healthcare.gov project, or at least all the components that easily lend themselves to open source. I think that some of it may already be open sourced. But instead of hiring an army of contract developers who will cost us so much money, harness an army of volunteers, who are likely better engineers, who will do the work for free.

That's what is increasingly done by technology companies and so much of the software that runs the web these days is open source. Why can't the software that runs our government be open sourced too? If you think this is a good idea, you can sign this petition. I signed it yesterday.

There is a lot going on in this area. My colleague Nick posted this link on usv.com today. GitHub now has a "subgit" on government projects. That's awesome and I hope we see the healthcare.gov codebase show up there soon.

As I've gotten into my 50s, something has occurred that has never been an issue for me, I've put on some weight. Nothing earth shattering but enough to get me focused on my weight for the first time ever.

So in the spirit of "you can't manage what you can't measure", I decided to get a scale. And because my friend Naveen is such a fan of the Withings scale, I went for that.

The Withings scale is a thing of beauty. It is sleek and looks great in my closet.

The scale measures your weight, body fat %, pulse rate, temperature, and CO2 levels in your home.

It connects to the wifi in your home and communicates with the Withings app on your iPhone and Android. You never have to connect anything to anything. The data flows over the air from scale to phone. The app provides a timeline of your key stats and gives you goal settings for them.

It's geek and chic at the same time. I'm into it and thought that some of you might be as well. Like most things, it is available at Amazon.